Reflections on 40 years as a doctor in Women's Health

Give Sorrow Words

It is fairly intuitive to suspect that parental mental health has an effect on both infant and childhood development. Indeed there is a widespread attempt to address the issue with the use of evaluative tests such as the Edinburgh Postnatal Depression Scale to identify or even anticipate and take action to ameliorate the problem.

It was designed, of course, to deal with the disastrous effects a mother’s depression, especially a postpartum one, might have on the health of the newborn -everything from bonding, to breast milk production, to the safety of the baby itself, could be jeopardized with an untreated depression. But, aside from the obvious issues of domestic violence, the father’s mental state is seldom accorded the same vigilance -after all, he is not the one who has undergone profound physiological and hormonal alterations as the pregnancy progresses, he is not the one who has experienced the rigours of delivery, and he is certainly not the one whose hormone levels change so drastically once again in the postpartum period.

And yet, merely to assign the paternal side of the parental equation to a largely supportive role is perhaps to assume there are few mental consequences of the changes that this newly acquired responsibility entails. It is the woman who is under the watchful eye of the accoucheur, and not the partner -even if he attends most of the prenatal visits. And postpartum period is likely even more of a black-hole for partner surveillance.

Although not adequately investigated, previous studies suggested that only between 4-10% of men developed recognizable post-partum depressive-like symptoms, whereas a Swedish study found that ‘28% of men had symptoms that scored above mild levels of depression. Overall, 4% had moderate depression. Fewer than one in five fathers who were depressed sought help, even though a third of those had thought about harming themselves.’ The discrepancy is likely because, unless it is serious, or obvious, the men are less frequently assessed in relation to their spouses pregnancy.

But the answer might not be as easy as asking the father-to-be to fill in the Edinburgh Depression Scale like his partner. ‘The lead author of the Swedish paper, Elisa Psouni, from the department of psychology at Lund University, says the Edinburgh Postnatal Depression Scale (EPDS) used for both women and men is not so accurate in picking up depression in fathers. Her research showed higher levels of depression in dads because it added in a score more reflective of “male” symptoms of depression such as agitation, anger, irritability, working longer hours and drinking too much.

‘Depression in fathers may be rising not just because researchers are looking for it, but because more new dads are struggling. Psouni believes fathers increasingly face the same dilemmas that mothers do – including trying to combine parenthood with working. Fathers who got depressed often had external pressures, such as job issues, and if their partner was depressed, their own risk of depression doubled. Lack of sleep, having twins and conflict in the relationship can all contribute.

‘A depressed dad will play and smile less with his child. Children are deeply affected by paternal postnatal depression with studies showing poorer measures of wellbeing and more behavioural problems at the age of seven.’

I was focussed, as were most obstetricians, on the mother of course, but even then I wondered about the effects of pregnancy on the dads.

*

Julie was sitting in the waiting room fussing with her new baby cradled ever so carefully in her arms. I recognized the older woman seated beside her -I’d met her mother several times before the delivery, and as a watchful guardian in the corner during the delivery- but I’d never seen Julie without her husband, Andrew. He’d come to every prenatal visit, and had hovered over her like a tent during her entire labour -at least those times when I was present, anyway.

They were a team, and as inseparable as a shirt from its tie -too inseparable, I sometimes thought. Each decision she had to make throughout the pregnancy -everything from prenatal supplements, types of analgesia in labour, to when to cut the umbilical cord after birth- was made after lengthy consultation between the two of them. She never seemed to be given the option of deciding for herself and yet she seemed to welcome his input. She basked in his concern; she waded in his eyes.

That day, I remember she insisted her mother stay in the waiting room with the baby while she had her routine post-partum check; it seemed a little unusual.

“You’re looking a bit tired, Julie,” I said, when I had finished my post-partum examination.

She nodded pleasantly, but she looked preoccupied. I assumed it was the usual new-mother state, though, and I was happy that her mother had agreed to stay with them for a while.

“Where’s Andrew,” I asked, more to change the subject than out of curiosity.

Her eyes suddenly surfaced from her lap and flew to my face. “Andrew?” she replied, a little too quickly, I thought. “Oh, he’s… at home…”

But there was hesitation in her answer -as if I was being invited to question her some more. “At home…?” I asked, gently. I could see some tears beginning to well up in her eyes. “Is he okay…?”

She sighed and fixed me with a melancholy shrug. “He’s been stressed a lot at work, I guess -he’s taken some time off…”

I leaned forward a bit on my desk to show her I was listening and her face collapsed.

“Soon after we got home with the baby, he began sitting around pretending to read, but he never turned the page. He didn’t want to go for walks with us, and he only played with his food… He started to argue…” She closed her eyes for a moment before resuming. “And even the baby didn’t seem to interest him anymore…” She stared out the window behind my desk, obviously uncertain how to proceed. I offered her some tissue from the box I keep on the desk and she wiped her cheeks. “He said he was afraid of hurting her…” she blurted out, uncoaxed.

Suddenly, she stared at me. “Can you imagine -he was afraid of hurting his own daughter..!”

I must have looked concerned, because she quickly sat back in her chair and almost smiled. “Yes,” she said, as if trying to reassure me. “I realized he was depressed -I’m a nurse, remember- so both of us went to his doctor a week or so ago. He was referred immediately to a specialist who put him on medications as well as enrolled him in some counselling sessions.” Just getting it off her chest seemed therapeutic, and the shadows of a tiny smile began to surface on her lips.

But nonetheless, she looked uncertain, and also perhaps a little bemused. “I didn’t think men could get post-partum depression, doctor.”

I smiled and relaxed in my chair while I riffled through my head for an explanation. “A new baby changes things for both of you, don’t you think? Only, he just doesn’t have the same hormones, Julie…” I added, not certain what more I could say about it.

She actually chuckled at the thought. “Damn! I was hoping you’d tell me he could do some of the nighttime breast feeding…”